Feasibility of a Managed Alcohol Program (MAP) for Sydney’s homeless

Researchers

Investigators

1. Nadine Ezard, Clinical Director, Alcohol & Drug Service, St Vincent’s Hospital (Principal Investigator)
2. Kate Dolan, Professor, National Drug & Alcohol Research Centre (NDARC), UNSW
3. Eileen Baldry, Professor of Criminology, Deputy Dean, Faculty of Arts and Social Sciences, UNSW
4. Lucy Burns, Associate Professor, National Drug & Alcohol Research Centre (NDARC)
5. Carolyn Day, Associate Professor, Addiction Medicine, Central Clinical School, University of Sydney

Research team

1. Sianne Hodge, Project and Research Coordinator, Alcohol & Drug Service, St Vincent’s Hospital
2. Tim Cubitt, Counsellor, Alcohol & Drug Service, St Vincent’s Hospital
3. Brayden Loesch, UNSW Forensic Masters Student
4. Thomas Mackay, UNSW Forensic Masters Student

Summary

Alcohol dependence affects almost half of Sydney’s homeless adult population. Alcohol dependent homeless people experience higher rates of chronic illness, injuries and assaults, longer hospital stays, increased mortality, and higher levels of contact with the criminal justice system. Many also suffer from mental illness and alcohol-related brain injury.

Managed Alcohol Programs (MAPs) are a novel approach for delivering health and social services to a population that has not responded to or engaged with existing services. MAPs operate within homeless shelters and involve dispensing a regulated amount of alcohol at set times to those with severe and intractable alcohol dependence. MAPs currently operate in Canada, the United States of America (USA), Norway, and the United Kingdom (UK). The establishment of a MAP in Sydney has been hampered by a lack of evidence of feasibility and acceptability. This study sought to address this gap by reviewing the literature, surveying potential MAP service users, and estimating costs and service utilisation savings offered by the establishment of a MAP in Sydney.

Outcomes

A systematic literature review was conducted between July and September 2014. A survey of eligible homeless alcohol dependent residents of the inner Sydney short stay alcohol withdrawal service, Gorman House, was conducted from 9 July to 3 November 2014. Participants were surveyed about four MAP models:

• day shelter with bring-your-own alcohol
• day shelter with one alcoholic drink provided every hour for 15 hours a day
• residential facility with bring-your-own alcohol
• residential facility with one alcoholic drink provided every hour for 15 hours a day.

The majority of respondents indicated strong interest in a MAP with a preference for the residential model (76 per cent expressed interest in the bring-your-own alcohol model and 69 per cent in a service where alcohol is provided). Willingness of respondents to pay a proportion (at least 25 per cent) of their income for the service was up to 90 per cent for a residential facility where alcohol is provided. In terms of location there was a preference for an inner city/Kings Cross area location (around a third preferred outside the city).

Findings demonstrate technical, operational, and economic feasibility of a MAP for Sydney. A 15-bed residential facility is estimated conservatively to result in a net reduction in service utilisation costs of around $480,000 per year (range $390,000-$580,000). Establishment of a rigorously evaluated MAP may herald an important policy shift in meeting the housing, social, health and welfare needs of homeless people with ongoing severe alcohol dependence. What is required next is the development of a MAP pilot implementation plan and model of care, commencing with stakeholder analysis and engagement.

Recommendations

MAPs represent a step forward in the development of alcohol policy in Australia. Although they are not yet established in Australia, international experience strongly suggests that they have the potential to reduce harm and improve individual wellbeing for people with chronic alcohol dependence and for whom treatment has not been successful. MAPs also have the potential to decrease costs and public nuisance to the community. Our survey of potential service users showed a positive response to a MAP, with more than two thirds expressing interest in using a MAP and more than three quarters willing to pay at least a quarter of their income to participate. We estimate conservatively that operating a 15-bed service in inner Sydney will result in a net benefit in reducing community service expenditure on this population of around $480,000 (range $390,000-$580,000) a year, taking into account the cost of providing such a service.

A very small proportion of Australians take up a disproportionate amount of community resources due to severe alcohol dependence, yet these resources are arguably utilised ineffectively. Embedded in a harm reduction approach, MAPs provide a rational alternative option for policy makers to address chronic intractable harmful alcohol use.

MAPs can also provide the opportunities for service collaboration and delivery for integrated models of care to better meet the needs of complex alcohol dependent populations. Establishment of a rigorously evaluated MAP has important implications for alcohol policy in Australia and internationally as it will build the evidence base for improved care of those with severe alcohol dependence.